Intraoperative Care

At York Teaching Hospital, during major elective procedures the Consultant Anaesthetist will aim to:

• Provide goal directed fluid therapy
• Use Hartmanns solution 250ml fluid boluses
• Fluid optimise to stroke volume variation <12% (16% in laparoscopic surgery)
• Use vasopressor infusions to maintain mean arterial pressure >65

At the end of surgery, the Anaesthetist will discuss with the surgeons the requirement for maintenance fluid. The aim is to have patients taking oral fluids post-operatively; if this is not possible or is not being tolerated the current preference is for an intravenous fluid infusion of 1ml/kg/hr dextrose saline (+/- KCL 20-40mmol),

A surgical APGAR score is performed at the end of surgery. If a patient has perviously been assessed as low risk and has a APGAR score that suggests high risk, they are immediately upgraded to an enhanced perioperative protocol.

	0	1	2	3	4
Estimated blood loss	>1000	601-1000	101-600	≤100
Lowest MAP	<40	40-54	55-69	≥70
Lowest HR	>85*	76-85	66-75	56-65	≤55

*Pathological bradycardia also scored as a 0

(0-4 points = very high risk 14% mortality, 75% major complications, 97% specific for ICU, 5-6= high risk, 4% mortality, 16% major complications, 7-8 = moderate risk, 1% mortality 6% major mortality, 9-10 Low risk 0% mortality, <4% major complications)

Recovery

Patients on a fluid optimisation protocol will have this commenced in recovery and recovery staff should be supported by one of our specialist nurses. Pulse contour analysis cardiac monitoring will continue in recovery. A lactate is measured prior to discharge from recovery and if this is >3mmol/L patients must be reviewed by an Anaesthetist.